Background Proper documentation in medical record is an essential component of quality care and a legal requirement for all medical practitioners1. This audit was designed following learning from a case of missed non-accidental injury in which documentation of X-ray review fall short of the standard set by Royal College of Radiologist (RCR)2.
Aim To determine if documentation of X-ray review in the paediatric department is up to the required standard.
Methods We audited two months’ period of activities in Paediatrics department against 3 RCR2 standards (see Table 1). A specially designed form was used to collect data from the electronic medical records and radiology system of all in-patients who had plain X-ray between July and August 2015.
Results Forty-nine patients’ medical notes were reviewed.
One in 5 of x-ray had no documentation of review in medical notes. One in 5 of X-ray requested from neonatal unit and 3 in 10 of those requested from the children ward have no documentation of review.
Out of the 39 patients who had documentation of their X-ray review, 51% had first review within 4 h and 62% within 24 h of imaging. The time of documentation was not specified in about a third (31%) of the sample.
Forty-seven percent had their final report 2–4 weeks after imaging but 4% did not have a formal report of their X-rays.
Conclusion Failure to document X-ray review in 20% of the sample fall short of standard. The average time lag of 2–4 weeks between imaging and radiologist report makes documentation of X-ray review more paramount. Also important is accurate documentation of time of X-ray review including name and status of reviewer.
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